An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline: Surveillance Strategies in Patients with Stage I, II, III or Resectable IV Melanoma Who Were Treated with Curative Intent

AIMS

To make recommendations on managing the surveillance of patients with stage I, II, III or resectable IV melanoma who are clinically free of disease following treatment with curative intent.

MATERIALS AND METHODS

This guideline was developed by Ontario Health's (Cancer Care Ontario's) Program in Evidence-Based Care and the Melanoma Disease Site Group (including seven medical oncologists, four surgical oncologists, three dermatologists, one radiation oncologist and one patient representative). The MEDLINE, EMBASE, Cochrane Library, PROSPERO databases and the main relevant guideline websites were searched. Internal and external reviews were conducted, with final approval by the Program in Evidence-Based Care and the Melanoma Disease Site Group. The Grading of Recommendations, Assessment, Development and Evaluation approach was followed, and the Modified Delphi method was used.

RESULTS

Based on the current evidence (eight eligible original study papers and four relevant guidelines) and the clinical opinions of the authors of this guideline, the initial recommendations were made. To reach 75% agreement for each recommendation, the Melanoma Disease Site Group (16 members) voted twice and one recommendation was voted on three times. After a comprehensive internal and external review process (including national and international reviewers), 12 recommendations, three weak recommendations and six qualified statements were ultimately made.

CONCLUSIONS

After a systematic review, a comprehensive internal and external review process and a consensus process, the current guideline has been created. The guideline authors believe that this guideline will help clinicians, patients and policymakers make well-informed healthcare decisions that will guide them in clinical melanoma surveillance and ultimately assist in improving patient outcomes.

Mini review: Breast cancer care in individuals with differences of sexual development

Disorders or differences of sexual development encompasses an important group of conditions that affects up to 1 in 5,000 live births. Many individuals living in the female gender includes Turner syndrome, congenital adrenal hyperplasia and conditions with 46XY karyotype such as gonadal dysgenesis (Swyer syndrome). Individuals are commenced on high dose oestrogen to initiate and maintain development of secondary sexual characteristics such as breasts which is paramount in them identifying in the female gender. We highlight the first case of a patient with Swyer syndrome who was treated with long term oestrogen therapy and later developed breast cancer. In individuals with gonadal dysgenesis, testicular malignancy is a recognised risk and is screened for. Prolonged exposure to exogenous and endogenous hormones can increase the risk of breast cancer however how much this risk increases in those taking high dose hormones is not documented in the literature. We aim to highlight the importance of breast cancer treatment and surgical reconstruction in this group and whether they should be considered for early breast cancer screening. CONCLUSION: It is imperative that triple assessment is undertaken in every patient with a breast lump, regardless of gender identification. Clinicians must not delay investigations in this patient group due to a misunderstanding of their condition. Those on long term hormone supplementation should be entered into the breast screening program at an earlier age with Magnetic Resonance Imaging surveillance. Careful consideration of post treatment endocrine therapy is required and under the care of the multi-disciplinary team.

An Efficient Watermarking Based Matrix Manipulation and Optimization Based Cryptographic Method for Privacy Preservation in Biomedical Data

The biomedical processing of images is an important aspect of the modern medicine field and has an immense influence on the modern world. Automatic device assisted systems are immensely useful in order to diagnose biomedical images easily, accurately and effectively. Remote health care systems allow medical professionals and patients to work from different locations. In addition, expert advice on a patient can be received within a prescribed period of time from a specialist in a foreign country or in a remote area. Digital biomedical images must be transmitted over the network in remote healthcare systems. But the delivery of the biomedical goods entails many security challenges. Patient privacy must be protected by ensuring that images are secure from unwanted access. Furthermore, it must be effectively maintained so that nothing will affect the content of biomedical images. In certain instances, data manipulation can yield dramatic effects. A biomedical image safety method was suggested in this work. The suggested method will initially be used to construct a binary pixel encoding matrix and then to adjust matrix with the use of decimation mutation DNA watermarking principle. Afterwards to defend the sub keys couple privacy which was considered over the logical uplift utilization of tent maps and purpose. As acknowledged by chaotic (C-function) development, the security was investigated similar to transmission in addition to uncertainty. Depending on the preliminary circumstances, various numbers of random were generated intended for every map as of chaotic maps. An algorithm of Multi scale grasshopper optimization resource with correlation coefficient fitness function and PSNR was projected for choosing the optimal public key and secret key of system over random numbers. For choosing the validation process of optimization is to formulate novel model more relative stable to the conventional approach. In conclusion, the considered suggested findings were contrasted with current approaches protection that was appear to be successful extremely.

Systemic adjuvant therapy for adult patients at high risk for recurrent cutaneous or mucosal melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline

Background

Previous versions of the guideline from the Program in Evidence-Based Care (pebc) at Ontario Health (Cancer Care Ontario) recommended that the use of high-dose interferon alfa 2b therapy be discussed and offered to patients with resected cutaneous melanoma with a high risk of recurrence. Subsequently, several clinical trials in patients with resected or metastatic melanoma found that immune checkpoint inhibitors and targeted therapies have a benefit greater than that with interferon. It was therefore considered timely for an update to the guideline about adjuvant systemic therapy in melanoma.

Methods

The present guideline was developed by the pebc and the Melanoma Disease Site Group (dsg). Based on a systematic review from a literature search conducted using medline, embase, and the Evidence Based Medicine Reviews databases for the period 1996 to 28 May 2019, the Working Group drafted recommendations. The systematic review and recommendations were then circulated to the Melanoma dsg and the pebc Report Approval Panel for internal review; the revised document underwent external review.

Recommendations

For patients with completely resected cutaneous or mucosal melanoma with a high risk of recurrence, the recommended adjuvant therapies are nivolumab, pembrolizumab, or dabrafenib-trametinib for patients with BRAF V600E or V600K mutations; nivolumab or pembrolizumab are recommend for patients with BRAF wild-type disease. Use of ipilimumab is not recommended. Molecular testing should be conducted to help guide treatment decisions. Interferon alfa, chemotherapy regimens, vaccines, levamisole, bevacizumab, bacillus Calmette-Guérin, and isolated limb perfusion are not recommended for adjuvant treatment of cutaneous melanoma except as part of a clinical trial.

Isolated diastolic hypertension and its risk factors in semi-rural population of South India

Background

Isolated diastolic hypertension (IDH) has been actively discussed for the last two decades because of its prevalence in a younger population and its association with cardiovascular disease. Furthermore, the association of IDH is significant in South Asian Countries such as India because relatively younger populations are known to have a higher risk of cardiovascular events.

Objective

The objective of this study is to find prevalence of IDH and its risk correlates in a semiurban population of South Indian state of Andhra Pradesh.

Methods

Data were collected using the modified World Health Organization - STEPwise approach to Surveillance (WHO STEPS) questionnaire for 16,636 individuals from a group of villages under Thavanampalle Mandal. Collated data were analyzed for prevalence and risk factors of IDH.

Results

Prevalence of IDH was found to be 4.0% with mean age of 46.0 (±SD 13.6) years and a relatively higher prevalence in men (5.3%) as compared with women (3.2%). The prevalence of IDH peaked in the fifth decade of life (40–49 years of age) and declined thereafter. Among various risk factors that were analyzed for their association with IDH, only age, body weight, and body mass index retained their significance in multivariate binary logistic regression analysis.

Conclusion

There is a significant prevalence of IDH below 50 years of age in the semiurban population of South India. As IDH in young and middle age is known to be associated with increased risk of cardiovascular events and end organ involvement, it highlights need for study and development of effective IDH management strategies to reduce associated morbidity and mortality.

Abstract 11: Novel dual inhibitors of LSD1-HDAC6/8 for treatment of cancer

Introduction: Lysine Specific Demethylase 1 (LSD1) is a flavin adenine dinucleotide (FAD)-dependent amine oxidase that has been reported to be over-expressed in many malignant tumors. Down-regulation of LSD1 has been shown to effectively treat cancers by inducing re-expression of aberrantly silenced genes. Studies have shown that LSD1 may contribute to acute myelogenous leukemia pathogenesis by inhibiting the normal pro-differentiative function of ATRA, paving the way for new combinatorial therapies for AML. Similarly, HDAC isoform selective inhibitors are beginning to be explored as less toxic alternatives to panHDAC inhibitors in select cancers. Further, combined inhibition of LSD1 and HDAC has been shown to be more efficacious in inhibiting multiple cancers. Here, we show that JBI-295, a dual inhibitor targeting both LSD1 and HDAC6/8 shows stronger efficacy without enhancing systemic toxicity, in a subset of AML and JAK-dependent myeloproliferative cancer.

Methods: Computational chemistry approaches were used to design LSD1 specific and LSD1-HDAC dual inhibitors. To assess in vitro LSD1 potency, TR-FRET assay was used. For assessing in vitro HDAC activity fluorescence based HDAC6 activity assay was performed. Western blotting was used to assess biomarkers of LSD1 and HDAC inhibition. Alamar blue cytotoxicity assay was used to assess cell proliferation.

Results: Several compounds from this series show strong in vitro potency against LSD1 with more than excellent selectivity against MAOs. JBI-295 one of the lead dual molecules, showed strong LSD1 potency (IC50 of 0.07 μM) and isoform selective HDAC6/8 activity (IC50 of 0.006 and 0.08 µM on HDAC6 and HDAC8, respectively), with about 100 fold selectivity against other HDAC isoforms. JBI-295 showed strong anti-proliferative activity on leukaemia and multiple myeloma cell lines. In cell based and in vivo target engagement studies there was a concomitant increase in CD11b, CD86 and GFI1b and tubulin acetylation levels. JBI-295 was more efficacious in inhibiting the growth of leukemia HEL92.1.7 xenograft by oral administration when compared to IP administration of ACY-1215, a HDAC6 selective inhibitor. Stronger tumor growth inhibition was also observed in melanoma A375 xenograft model as compared to inhibitors with single activity. In addition, JBI-295 showed single agent activity in a syngeneic murine colon cancer model CT26 and also resulted in stronger tumor growth inhibition when combined with anti-PDL1 antibody.

Conclusion: The data obtained demonstrate that dual LSD1-HDAC6/8 inhibitors could serve as novel, effective therapeutic agents for treatment of select subset of cancer. Advanced efficacy and toxicology studies with JBI-295 are in progress.

Citation Format: Dhanalakshmi Sivanandhan, Sridharan Rajagopal, Sreekala Nair, Chandru Gajendran, Dimpy Ghosh, P Nagaraj, Subramanyam J. Tantry, Purushottam Dewang, Mahanandeesha S. Hallur, Kannan Murugan, Srinatha K. C, Damodara Kuntrapaku, M Dilipkumar, R Sharma, S Meghashree, Durga Prasanna Kumar, Suraj P. Ingle, Mohd Zainuddin, A B. Vinod, Sriram Rajagopal. Novel dual inhibitors of LSD1-HDAC6/8 for treatment of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 11.

P91 Post-operative pain in neurosurgery

Objectives

Are the analgesic guidelines for those neurosurgical operations associated with major and complex major pain consistently followed? Is there a correlation between adherence and post-operative pain?

Design

Patients undergoing spinal surgery and foramen magnum decompressions were visited on the first post-operative day (D1). They provided their pain score subjectively (0=nil; 10=worst ever experienced); objectively we recorded whether they could move in/out of bed without pain limitation.

Subjects

n=57 consecutive patients undergoing elective major and complex major pain neurosurgery between April and June 2018 at the NHNN, Queen Square.

Methods

A proforma was completed on D1. The patients consented to take part and answered three questions. We examined what (if any) analgesics they were admitted on, and what had been prescribed to cover the post-operative period. This was compared against the appropriate guideline for that category of operation.

Results

Guidelines were only followed in 16/57 (28.1%) cases; not followed in 41/57 (71.9%). On an unpaired T-test: 2-tailed P value=0.0195. Where guidelines were followed, the mean pain score reported was: 3.75 (SD 2.72) Where not followed, the mean pain score was 5.46 (SD 2.29). So with a 95% confidence interval −3.41 to −0.29, there is a significant difference between the pain in those prescribed according to the guidelines and those that were not.

Conclusions

The pain guidelines are not routinely followed. Most commonly this was due to no prescription for a non-steroidal anti-inflammatory agent. We suggest regular sessions of education of the guidelines. Cycle 2 closed the loop of the audit. We re-reviewed adherence and pain scores and found guidelines were followed in 34% of cases, which represented a 6% improvement. On a paired two-tailed P value=0.0794. The mean pain score where guidelines were followed=3.42 (SD1.62) against a mean=4.74 (SD 1.89) where guidelines were not followed.

Abstract 5860: Novel, first-in-class dual inhibitors of lysine specific demethylase 1 (LSD1) and histone deacetylatse 1 (HDAC) for treatment of cancer

Introduction: LSD1 is a flavin adenine dinucleotide (FAD)-dependent amine oxidase that removes methyl groups from mono- or dimethylated histone H3 lysine 4. Studies have shown that LSD1 contributes to acute myelogenous leukaemia pathogenesis and patients that are non responders to ATRA respond to LSD1-ATRA combination treatment in clinic. Recent studies have shown that there is cross-talk between two components of CoREST complex, LSD1 and HDAC1/2 and combined inhibition of these targets has been shown to be more efficacious in multiple cancers. Therefore, dual inhibitors targeting both LSD1 and HDAC could be useful in treating cancers. To test the hypothesis, we have developed a set of molecules that have dual activity on LSD1 and HDACs.

Methods: To assess in vitro LSD1potency, TR-FRET assay was used. For assessing HDAC activity fluorescence based HDAC activity assay was performed. Western blotting and RT-qPCR were used to assess biomarkers of LSD1 and HDAC1/2 inhibition. Alamar blue cytotoxicity assay was used to assess cell proliferation. Xenograft models were used to assess in vivo efficacy.

Results: Dual inhibitors show strong in vitro potency comparable to advanced clinical candidates, against LSD1. On HDAC1/2 these molecules showed comparable IC50 as marketed HDAC1/2 specific drugs. Interestingly, these dual inhibitors lead to stronger and complete inhibition of cell proliferation in broader types of cancer cell lines, including, acute myeloid leukemia, multiple myeloma, hepatocellular carinoma and small cell lung cancer when compared to LSD1 specific inhibitor GSK2879552. Target engagement studies confirm the concomitant increase in mRNA levels of GFI1b, CD11b, CD86 and H3K9 acetylation levels. In vitro activity also shows a clear translation in efficacy studies. JBI128, one of the lead molecules from this series was tested in multiple in vivo studies, including, non-small cell and small cell lung cancer, where it not only shows single agent activity, but can also be combined with other targeted agents or SoC safely. In addition, combination of JBI128 with immune checkpoint inhibitor anti-PDL1 antibody in the CT26 syngeneic model showed much stronger efficacy as compared to either of the single agents. This clearly suggests that these dual inhibitors in addition to being epigenetic modulators in the cancer cells also have a role in immune modulation thereby contributing to stronger efficacy. Further studies in terms of gene expression analysis are underway to understand the molecular mechanism behind the additional activity/efficacy of these dual inhibitors.

Conclusion: These LSD1-HDAC dual inhibitors have the potential to be developed as first-in-class therapies that could offer stronger clinical efficacy compared to LSD1 or HDAC inhibitor alone. Further mechanistic and combination studies with standard therapies are in progress.

Citation Format: Dhanalakshmi Sivanandhan, Sreekala Nair, Subramaniyam Tantry, Sridharan Rajagopal, Mahanandeesha Hallur, Kannan M, Srinatha KC, Damodara K, Dilipkumar M, Chandru G, Dimpy Ghosh, Pradeep N, Anuj Kumar Singh, Mohd Zainuddin, Rudresh G, Radha Sharma, Meghashree S, Durga P. Kumar, Purushottam Dewang, Sriram Rajagopal. Novel, first-in-class dual inhibitors of lysine specific demethylase 1 (LSD1) and histone deacetylatse 1 (HDAC) for treatment of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5860.

Abstract 5552: Novel, heterocyclic small molecule inhibitors of PD-1 and PD-L1 pathway

The PD-1/PD-L1 molecular pathway is one of the primary mechanisms of immune evasion deployed by cancer cells. Induction of PD-L1 expression on cancer cells is associated with inhibition of immune responses against cancer, thus permitting cancer progression and metastasis. Activation of PD-1/PD-L1 pathway induces apoptosis of activated T-cells, inhibits their proliferation, facilitates T-cell anergy and exhaustion and enhances the function of regulator T-cells. Therefore, blocking this pathway restores the proliferation and cytotoxicity of CTLs, inhibits the function of Tregs and results in decreased T-cell apoptosis. A number of cancer immunotherapy agents targeting PD-1/PD-L1 have been developed and approved for a number of malignancies (PD-1: Nivolumab, Pembrolizumab, PD-L1: Atezolizumab, Avelumab, Durvalumab). However, there is a still a need for potent, selective small molecule inhibitors of the PD-1/PD-L1 pathway. The approved therapies require bolus intravenous injections, are administered in high dose and have a long half life. The long residence time of these mAbs could contribute to the well-documented drug-related adverse effects. Small molecule inhibitors, therefore, can provide increased oral bioavailability, increased bio-efficiency and shorted half life activity for a more controllable treatment, particular in the case of auto-immune or other adverse effects. Rational and structure guided de novo design approaches were used to design novel small molecule PD-1/PD-L1 pathway inhibitors; potency of these inhibitors was assessed in an in-vitro TR-FRET assay. Checkpoints signaling reporter assays as well as ex-vivo co-culture assays were used to assess the ability of the compounds to restore T-cell proliferation and function. Three novel chemical series as potent PD-1/PD-L1 pathway inhibitors are being developed for the treatment of cancer. Compounds from these series showed strong in vitro potency of 0.01 to 0.2 µM against PD-1/PD-L1. JBI-426 exhibited an IC50 of 0.04 µM and no cytotoxicity against cancer cell proliferation per se. JBI-426 showed good in vitro ADME properties in terms of aqueous solubility, metabolic stability, permeability and excellent oral bioavailability in mouse pharmacokinetics. In a RENCA syngeneic model, oral administration of JBI-426 at 50 mg/kg resulted in a strong tumor growth inhibition, comparable (or better) than the PD-L1 mAb, and was well tolerated. The effect of JBI-426 on tumor infiltrating lymphocytes was also assessed; a significant increase in CD8+ cytotoxic lymphocytes was observed. Further studies to assess additional compounds from the three chemical series are underway. The oral administration route of these PD-1/PD-L1 inhibitors would provide an attractive alternate to the currently available antibodies in treating cancer either as a stand-alone therapy or in combination with other immuno-modulatory agents, as well as other standard of care agents.

Citation Format: Sivanandhan Dhanalakshmi, Shivani Garapaty, Chandregowda Venkateshappa, Guru Pavan Seerapu, Reshma Das, Pradeep Nagaraj, Ronodip Kar, Anuj Kumar Singh, Venkatesha Ashokkumar Venkatesubbiah, Ramakishore VP Putta, Muralidhar Pendyala, Girisha Lokesh, Hari Madaka, Harikrishna Reddy Thummuru, Shikas AP, Prateeksha Anchan, Prathima Bhat, Rudresha G, Mohd Zainuddin, Krishnakumar V, Ramachandraiah Gosu, Rajendra Kristam, Jeyaraj DA, Sriram Rajagopal. Novel, heterocyclic small molecule inhibitors of PD-1 and PD-L1 pathway [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5552.

Abstract 1382: Novel dual inhibitors of LSD1-HDAC6/8 for treatment of cancer

LSD1 is an FAD-dependent amine oxidase that removes methyl groups from mono- or dimethylated histone H3 lysine 4 (H3-K4) as a part of CoREST repressor complex. Recent studies have shown that there is crosstalk between two components of CoREST complex, LSD1 and HDAC, which provides an advantage to cancer cell proliferation and survival by regulating key signaling pathways. Accordingly, combined inhibition of LSD1 and HDAC has been shown to be more efficacious in inhibiting the growth of glioblastoma, AML and breast cancer. Therefore, dual inhibitors targeting both LSD1 and HDAC could be useful in treating several cancers effectively without enhancing systemic toxicity mediated by administration of multiple drugs. To test the hypothesis, we have developed a set of molecules that either have LSD1 activity alone or dual activity on LSD1 and HDAC. Computational chemistry approaches were used to design LSD1-HDAC dual inhibitors. In vitro LSD1 potency was assessed by TR-FRET assay and in vitro HDAC activity by fluorimetric HDAC activity assay. Western blotting and RT qPCR were used to assess biomarkers of LSD1 and HDAC inhibition. Alamar blue cytotoxicity assay was used to assess cell proliferation. Multiple compounds from this series show an in vitro potency of less than 0.05 μM against LSD1 with more than 100-fold selectivity against MAOs. The dual inhibitors showed stronger activity on HDAC6/8. JBI-097, one such dual molecule with LSD1/HDAC/6/8 selectivity, showed an IC50 of 0.007uM on LSD1 and an IC50 of 0.06 and 0.1uM on HDAC6 and HDAC8, respectively, with about 100-fold selectivity against other HDAC isoforms. JBI-097 showed strong antiproliferative activity on leukemia and multiple myeloma cell lines. In MM.1S cell line, JBI-097 showed stronger potency when compared to LSD1 inhibitor GSK2879552 and HDAC6 inhibitor ACY1215. In cell-based and in vivo target engagement studies there was a concomitant increase in CD11b, CD86 and GFI1b and tubulin acetylation levels. JBI-097 was more efficacious in inhibiting the growth of HEL92.1.7 xenograft by oral administration when compared to IP administration of an HDAC inhibitor. In MM.1S tumor model, JBI-097 showed stronger effect in inhibiting tumor growth when compared to LSD1 inhibitor and HDAC6 inhibitor used as single agents. Further, combination with topotecan resulted in complete tumor growth inhibition of MM.1S xenograft. The data obtained demonstrate that it is feasible to design dual LSD1-HDAC6/8 inhibitors that retain individual activity and potently inhibit cell proliferation, and such inhibitors could serve as powerful therapeutic agents for cancer. Further understanding of mechanisms to identify the right tool compound is in progress.

Citation Format: Sivanandhan Dhanalakshmi, Sridharan Rajagopal, Sreekala Nair, Chandru Gajendran, Dimpy Ghosh, Subramanyam Janardhan Tantry, Purushottam Dewang, Mahanandeesha Hallur, M Kannan, Srinatha KC, Damodara Kuntrapaku, M Dilipkumar, Radha Sharma, S Meghashree, D P. Kumar, Mohd Zainuddin, A B. Vinod, Sriram Rajagopal. Novel dual inhibitors of LSD1-HDAC6/8 for treatment of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1382.

Diagnostic yield in the evaluation of dysphagia: experience at a single tertiary care center

Evaluation of dysphagia typically starts with esophagogastroduodenoscopy (EGD); further testing is pursued if this is negative. When no mucosal, structural, or motor esophageal disorders are identified with persisting symptoms, functional dysphagia is considered. We evaluated outcomes in patients undergoing EGD for dysphagia, and estimated prevalence of functional dysphagia. The endoscopy database at single tertiary care center was interrogated to identify EGDs performed for an indication of 'dysphagia' over a 12-month period (2008-09). Electronic medical records were reviewed over the next 8 years to assess if an etiology was identified. Data were analyzed to assess the diagnostic yield of endoscopy and subsequent tests in the evaluation of dysphagia. Of 5486 EGDs, 822 (15.0%) were performed for dysphagia in 694 patients (58.4 ± 0.6 year, range: 18-95 year, 55.8% female). Of these, 529 (76.2%) had EGD findings that explained dysphagia; another 22 (3.2%) had findings on histopathology. Of the remainder 143 patients (20.6%) with normal index EGD, 38 (26.6%) patients underwent barium esophagram with 15 (39.5%) having abnormal studies. 19 patients (13.3%) underwent esophageal high resolution manometry with 12 (63.2%) being abnormal, and 7 had a mechanism for dysphagia on alternate testing. A repeat EGD was abnormal in 6 patients, while 45 patients were lost to follow-up. 42 patients had complete resolution of symptoms despite normal endoscopy, of which 30 were treated empirically with a proton pump inhibitor (PPI). Only 16 patients had no findings on evaluation, and had continued dysphagia symptoms, representing true functional dysphagia in 2.3% of all dysphagia patients and 11.2% of patients with normal EGD. Endoscopy remains the test with the highest yield (over 75%) for a diagnosis in patients presenting with dysphagia; secondary tests are useful when endoscopy does not provide a diagnosis. Benign strictures and GERD-related etiologies are leading causes; PPI therapy is useful even when testing is negative. Functional dysphagia is extremely rare, accounting for <2.5% of all dysphagia.

PLK4: a link between centriole biogenesis and cancer

INTRODUCTION

Polo like kinase (PLK) is known to play a pivotal role in various cell cycle processes to perpetuate proper division and growth of the cells. Polo like kinase-4 (PLK4) is one such kinase that appears in low abundance and plays a well-characterized role in centriole duplication. PLK4 deregulation (i.e. both overexpression and depletion of PLK4), leads to altered mitotic fidelity and thereby triggers tumorigenesis. Hence, over the last few years PLK4 has emerged as a potential therapeutic target for the treatment of various advanced cancers. Areas covered: In this review, we discuss the basic structure, expression, localization and functions of PLK4 along with its regulation by various proteins. We also discuss the role of altered PLK4 activity in the onset of cancer and the current pre-clinical and clinical inhibitors to regulate PLK4. Expert opinion: PLK4 mediated centriole duplication has a crucial role in maintaining mitotic correctness in normal cells, while its deregulation has a greater impact on genesis of cancer. Henceforth, a deep knowledge of the PLK4 levels, its role and interactions with various proteins in cancer is required to design effective inhibitors for clinical use.

LC-MS/MS determination of tideglusib, a novel GSK-3β inhibitor in mice plasma and its application to a pharmacokinetic study in mice

A sensitive, specific and rapid LC-ESI-MS/MS method has been developed and validated for the quantification of tideglusib in mice plasma using warfarin as an internal standard (I.S.) as per regulatory guidelines. Sample preparation was accomplished through liquid-liquid extraction process. Chromatographic separation was performed on Atlantis dC₁₈ column using mobile phase A (acetonitrile) and B (5mM ammonium acetate in water) in a flow-gradient mode. Elution of tideglusib and the I.S. occurred at ∼2.06 and 1.29min, respectively. The total chromatographic run time was 3.2min. A linear response function was established in the concentration range of 20.2-1008ng/mL. The intra- and inter-day accuracy and precision were in the range of 4.61-12.6 and 6.04-11.8%, respectively. This novel method has been applied to a pharmacokinetic study in mice.

Immuno-detection of cleaved SNAP-25 from differentiated mouse embryonic stem cells provides a sensitive assay for determination of botulinum A toxin and antitoxin potency

Botulinum toxin type A is a causative agent of human botulism. Due to high toxicity and ease of production it is classified by the Centres for Disease Control and Prevention as a category A bioterrorism agent. The same serotype, BoNT/A, is also the most widely used in pharmaceutical preparations for treatment of a diverse range of neuromuscular disorders. Traditionally, animals are used to confirm the presence and activity of toxin and to establish neutralizing capabilities of countermeasures in toxin neutralization tests. Cell based assays for BoNT/A have been reported as the most viable alternative to animal models, since they are capable of reflecting all key steps (binding, translocation, internalization and cleavage of intracellular substrate) involved in toxin activity. In this paper we report preliminary development of a simple immunochemical method for specifically detecting BoNT/A cleaved intracellular substrate, SNAP-25, in cell lysates of neurons derived from mouse embryonic stem cells. The assay offers sensitivity of better than 0.1LD50/ml (3fM) which is not matched by other functional assays, including the mouse bioassay, and provides serotype specificity for quantitative detection of BoNT/A and anti-BoNT/A antitoxin. Subject to formal validation, the method described here could potentially be used as a substitute for the mouse bioassay to measure potency and consistency of therapeutic products.

Validated LC-MS-MS Method for Determination of SF0034 in Mice Plasma: Application to a Pharmacokinetic Study in Mice

A rapid and sensitive assay method has been developed and validated using liquid chromatography coupled to tandem mass spectrometry with electrospray ionization in the positive-ion mode for the estimation of SF0034 in mice plasma. The assay procedure involves a simple protein precipitation of SF0034 and tolbutamide (internal standard, IS) from mice plasma. Chromatographic separation was performed on an Atlantis dC18 column using an isocratic mobile phase comprising 0.2% formic acid:acetonitrile (10:90, v/v) at a flow rate of 0.60 mL/min. The total run time was 2.5 min. For mass spectrometric detection, the multiple reaction monitoring was used and ion transitions monitored were m/z 322 → 248 for SF0034 and 271 → 155 for IS. Method validation was performed as per regulatory guidelines and the results met the acceptance criteria. A calibration curve was constructed in the range of 2.08-2,078 ng/mL. The intra- and inter-day precision was in the range of 1.06-14.4% and 7.16-11.7%, respectively. This novel method has been applied to a pharmacokinetic study in mice.

Abstract 5578: Small molecule modulators to understand the role of IDO1 and TDO2 in cancer

Introduction: Tumor immune escape mechanisms have been established as suitable targets for cancer therapy. Among these, tryptophan catabolism plays a central role in creating an immunosuppressive environment, leading to tolerance to potentially immunogenic tumor antigens. Tryptophan catabolism is initiated by either indoleamine 2,3-dioxygenase (IDO1/2) or tryptophan 2,3-dioxygenase 2 (TDO2), resulting in biostatic tryptophan starvation and l-kynurenine production. Recent literature has shown that IDO1 and TDO2 are expressed in multiple tumors, including solid tumors and play key roles in tumor progression other than immune escape. It has also been shown that IDO1 and TDO2 play distinct roles in driving the downstream effectors suggesting that their roles are perhaps non-redundant. Therefore, we developed series of novel small molecule modulators against IDO1 and TDO2 to understand their role in disease biology for multiple indications including cancer, depression and autoimmune disorders.

Methods: Rational design approaches were used to design novel IDO1 and TDO2 specific modulators; Potency of these inhibitors was assessed in the in vitro assays using purified IDO1 and TDO2 enzymes and in IDO1 and TDO2 over-expressing HEK293T cells by measuring the formation of kynurenine.

Results: In the in vitro biochemical assay using purified human TDO2, one of the NCEs from inhibitor series showed an IC50 of 0.09 μM against TDO2. Against purified human IDO1, this compound was inactive up to 30 μM, thereby showing &gt;300-fold selectivity against IDO1. This TDO2 inhibitory activity translated well in TDO2-overexpressing HEK293 cells and, these NCEs inhibited kynurenine formation with an EC50 of ~2.5 μM. A second chemical series showed comparable dual inhibition of IDO1 and TDO2 activity. One of the molecules from this series showed IC50 of 0.2 and 0.08 μM in the biochemical assay and 1.7 and 0.8 μM in the cell based assay against IDO1 and TDO2, respectively. In addition, another series of NCEs showed strong activation of IDO1 and TDO2 activity. As compared to untreated control, formation of kynurenine was increased in a dose-dependent manner as observed by increase in fluorescence up to of 3-10 folds. One of the compounds from this series showed an EC50 of ~20- 30 μM in the biochemical assay as well as in 293T-based assay. Further mechanistic studies to understand the immune modulatory activity of these selective TDO2 modulators is underway. These tool compounds are being further optimized for potency and ADME properties to be developed as potential drug candidates.

Conclusion: To our knowledge such IDO1 and TDO2 specific small molecule activators have not been reported earlier. Therefore, these activators and inhibitors would serve as useful tool compounds in understanding the specific role(s) of IDO1 and TDO2 in disease biology and would also provide us the opportunity to target this pathway for various diseases, including cancer.

Citation Format: Shivani Rao Garapaty, Dhanalakshmi Sivanandhan, Guru Pavan Kumar Seerapu, Surendra Naidu, Shalini Chakelam, Pradeep Nagaraj, Reshma Das, Saravanan Vadivelu, Pravin Iyer, Chandrika Mulakala, Kannan Murugan, Somnath Mondal, Anjali Gautam, Saravanan Kandan, Manish Kumar Thakur, Sridharan Rajagopal, Sriram Rajagopal. Small molecule modulators to understand the role of IDO1 and TDO2 in cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5578. doi:10.1158/1538-7445.AM2017-5578

PAD4: pathophysiology, current therapeutics and future perspective in rheumatoid arthritis

INTRODUCTION

Peptidyl arginine deiminase 4 (PAD4) is an enzyme that plays an important role in gene expression, turning out genetic code into functional products in the body. It is involved in a key post translational modification, which involves the conversion of arginine to citrulline. It regulates various processes such as apoptosis, innate immunity and pluripotency, while its dysregulation has a great impact on the genesis of various diseases. Over the last few years PAD4 has emerged as a potential therapeutic target for the treatment of rheumatoid arthritis (RA). Areas covered: In this review, we discuss the basic structure and function of PAD4, along with the role of altered PAD4 activity in the onset of RA and other maladies. We also elucidate the role of PAD4 variants in etiology of RA among several ethnic groups and the current pre-clinical inhibitors to regulate PAD4. Expert opinion: Citrullination has a crucial role in RA and several other disorders. Since PAD4 is an initiator of the citrullination, it is an important therapeutic target for inflammatory diseases. Therefore, an in depth knowledge of the roles and activity of PAD4 is required to explore more effective ways to conquer PAD4 related ailments, especially RA.

Emerging role of SETDB1 as a therapeutic target

INTRODUCTION

Epigenetic changes lead to aberrant gene expression in cancer. SETDB1, a histone lysine methyltransferase plays an important role in methylation and gene silencing. Aberrant histone methylation at H3K9 by SETDB1 promotes silencing of tumor suppressor genes and thus contributes to carcinogenesis. Recent studies indicate that SETDB1 is abnormally expressed in various human cancer conditions which contributed to enhanced tumor growth and metastasis. Hence, SETDB1 appears to be a promising epigenetic target for therapeutic intervention. Areas covered: In this article, the structural features, localization and functions of SETDB1 are reviewed. Also, an overview of the role of SETDB1 in cancer and other disease mechanisms, the currently studied inhibitors for SETDB1 are mentioned. Expert opinion: Silencing of tumor suppressor genes due to excessive trimethylation at H3K9 by amplified SETDB1 levels is found in various cancerous conditions. Since epigenetic changes are reversible, SETDB1 holds promise as an important therapeutic target for cancer. Therefore, a better understanding of the role of SETDB1 and its interaction with various proteins in cancer-related mechanisms along with therapeutic interventions specific for SETDB1 may improve targeted cancer therapy.

Therapeutical potential of deregulated lysine methyltransferase SMYD3 as a safe target for novel anticancer agents

INTRODUCTION

SET and MYND domain containing-3 (SMYD3) is a member of the lysine methyltransferase family of proteins, and plays an important role in the methylation of various histone and non-histone targets. Proper functioning of SMYD3 is very important for the target molecules to determine their different roles in chromatin remodeling, signal transduction and cell cycle control. Due to the abnormal expression of SMYD3 in tumors, it is projected as a prognostic marker in various solid cancers. Areas covered: Here we elaborate on the general information, structure and the pathological role of SMYD3 protein. We summarize the role of SMYD3-mediated protein interactions in oncology pathways, mutational effects and regulation of SMYD3 in specific types of cancer. The efficacy and mechanisms of action of currently available SMYD3 small molecule inhibitors are also addressed. Expert opinion: The findings analyzed herein demonstrate that aberrant levels of SMYD3 protein exert tumorigenic effects by altering the epigenetic regulation of target genes. The partial involvement of SMYD3 in some distinct pathways provides a vital opportunity in targeting cancer effectively with fewer side effects. Further, identification and co-targeting of synergistic oncogenic pathways is suggested, which could provide much more beneficial effects for the treatment of solid cancers.

Validation of an LC-MS/MS method for simultaneous detection of four HDAC inhibitors - belinostat, panobinostat, rocilinostat and vorinostat in mouse plasma and its application to a mouse pharmacokinetic study

A sensitive and rapid LC-MS/MS method was developed and validated for the simultaneous quantitation of four HDAC inhibitors, namely belinostat (BST), panobinostat (PST), rocilinostat (RST) and vorinostat (VST), in mouse plasma as per regulatory guidelines. The analytes and internal standard were extracted from 50 μL mouse plasma by protein precipitation, followed by chromatographic separation using an Atlantis C₁₈ column with an isocratic mobile phase comprising 0.1% formic acid-acetonitrile (25:75, v/v) at a flow rate of 0.5 mL/min within 2.5 min. Detection and quantitation were done by multiple reaction monitoring on a triple quadrupole mass spectrometer following the transitions: m/z 319 → 93, 350 → 158, 434 → 274 and 265 → 232 for BST, PST, RST and VST, respectively, in the positive ionization mode. The calibration curves were linear from 2.92 to 2921 ng/mL for BST and PST and from 1.01 to 1008 ng/mL for RST and VST with r²  ≥ 0.99 for all of the analytes. The intra- and inter-batch accuracy and precision (CV) across quality controls varied from 85.5 to 112% and from 2.30 to 12.5, respectively, for all of the analytes. Analytes were found to be stable under different stability conditions. The method was applied to an i.v. pharmacokinetic study in mice.

Determination of epacadostat, a novel IDO1 inhibitor in mouse plasma by LC-MS/MS and its application to a pharmacokinetic study in mice

A sensitive, specific and rapid LC-ESI-MS/MS method has been developed and validated for the quantification of epacadostat in mouse plasma using tolbutamide as an internal standard (IS) as per regulatory guidelines. Sample preparation was accomplished through a protein precipitation. Chromatographic separation was performed on an Atlantis dC₁₈ column using a binary gradient using mobile phase A (acetonitrile) and B (0.2% formic acid in water) at a flow rate of 0.90 mL/min. Elution of epacadostat and IS occurred at ~2.41 and 2.51 min, respectively. The total chromatographic run time was 3.2 min. A linear response function was established in the concentration range of 1.07-533 ng/mL. The intra- and inter-day accuracy and precision were in the ranges of 1.81-12.9 and 3.80-11.1%, respectively. This novel method has been applied to a pharmacokinetic study in mice.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Systematic synthesis and analysis of change in morphology, electronic structure and photoluminescence properties of 2,2′-dipyridyl intercalated MoO3 hybrid nanostructures and investigation of their photocatalytic activity

An organic–inorganic hybrid was synthesized using 2,2′-dipyridyl and MoO₃ nanorods via simple hydrothermal method. Here, dipyridyl has acted as stretching molecule and bonded the MoO₃ nanorods together along the length to form hybrid micro crystals.

Sensitive method for the determination of rocilinostat in small volume mouse plasma by LC-MS/MS and its application to a pharmacokinetic study in mice

A highly sensitive, specific and rapid LC-ESI-MS/MS method has been developed and validated for the quantification of rocilinostat in small volume mouse plasma (20 μL) using vorinostat as an internal standard (IS) as per regulatory guidelines. Sample preparation was accomplished through a protein precipitation procedure with acetonitrile. Chromatography was achieved on Prodigy ODS-2 column using a binary gradient using mobile phase A (0.2% formic acid in water) and B (acetonitrile) at a flow rate of 0.38 mL/min. The total chromatographic run time was 4.1 min and the elution of rocilinostat and IS occurred at ~3.2 and 2.9 min, respectively. A linear response function was established in the concentration range of 0.28-1193 ng/mL in mouse plasma. The intra- and inter-day accuracy and precisions were in the ranges of 3.12-8.93 and 6.41-11.6%, respectively. This novel method has been applied to a pharmacokinetic study in mice. Copyright © 2016 John Wiley & Sons, Ltd.

Breaking the sensitivity limitations of cytochrome P450 oxidation product: dansyl chloride derivatisation of 4-OH mephenytoin, a CYP2C19 metabolite and its application to in vitro CYP inhibition assay

A rapid selective and sensitive liquid chromatography/tandem mass spectrometry (LC-MS/MS) method was developed for the quantitative determination of derivatised cytochrome P450-2C19 oxidation product (dansyl-4-OH mephenytoin) and its underivatised form (4-OH mephenytoin). Samples were anaysed on C18 column (Waters Xbridge, 50 mm×4.6 mm, 3.5 μm particle size) with the mobile phase consisting of 0.1% formic acid in water and 0.1% formic acid in acetonitrile. A gradient method with a short run time of 2.5 min and 3.5 min was developed for the analysis of dansyl-4-OH mephenytoin and 4-OH mephenytoin, respectively. The standard curve was linear (r(2)=0.9972 for 4-OH mephenytoin; r(2)=0.9946 for dansyl-4-OH mephenytoin) over the concentration range of 0.16 to 40 ng/mL for both derivatised and underivatised forms. The CV (%) and relative error (RE) for inter and intraassay at three QC levels for dansyl-4-OH mephenytoin was 0.97-5.85% and -9.80 to 2.51%, respectively. Whereas, for 4-OH mephenytoin the CV (%) and RE (%) at three QC levels was 0.82-3.47% and -6.69 to -0.01%, respectively. The developed method was validated for various parameters such as linearity, precision & accuracy, extraction recovery, matrix effect, autosampler stability and was proved to be consistent across three QC levels with overall CV (%) less than 15. Dansylation helped in increasing the sensitivity of hydroxy mephenytoin by 100-200 fold. Given the simplicity involved in derivatisation process, we believe that this novel methodology will change the current approaches used for the enhancing the detection sensitivity of 4-OH mephenytoin.

Breaking the sensitivity limitations of cytochrome P450 oxidation product: dansyl chloride derivatisation of 4-OH mephenytoin, a CYP2C19 metabolite and its application to in vitro CYP inhibition assay

A rapid selective and sensitive liquid chromatography/tandem mass spectrometry (LC-MS/MS) method was developed for the quantitative determination of derivatised cytochrome P450-2C19 oxidation product (dansyl-4-OH mephenytoin) and its underivatised form (4-OH mephenytoin). Samples were anaysed on C18 column (Waters Xbridge, 50 mm×4.6 mm, 3.5 μm particle size) with the mobile phase consisting of 0.1% formic acid in water and 0.1% formic acid in acetonitrile. A gradient method with a short run time of 2.5 min and 3.5 min was developed for the analysis of dansyl-4-OH mephenytoin and 4-OH mephenytoin, respectively. The standard curve was linear (r(2)=0.9972 for 4-OH mephenytoin; r(2)=0.9946 for dansyl-4-OH mephenytoin) over the concentration range of 0.16 to 40 ng/mL for both derivatised and underivatised forms. The CV (%) and relative error (RE) for inter and intraassay at three QC levels for dansyl-4-OH mephenytoin was 0.97-5.85% and -9.80 to 2.51%, respectively. Whereas, for 4-OH mephenytoin the CV (%) and RE (%) at three QC levels was 0.82-3.47% and -6.69 to -0.01%, respectively. The developed method was validated for various parameters such as linearity, precision & accuracy, extraction recovery, matrix effect, autosampler stability and was proved to be consistent across three QC levels with overall CV (%) less than 15. Dansylation helped in increasing the sensitivity of hydroxy mephenytoin by 100-200 fold. Given the simplicity involved in derivatisation process, we believe that this novel methodology will change the current approaches used for the enhancing the detection sensitivity of 4-OH mephenytoin.

Liquid chromatography/tandem mass spectrometry method for quantitative estimation of solutol HS15 and its applications

A rapid, sensitive and selective pseudoMRM (pMRM)-based method for the determination of solutol HS15 (SHS15) in rat plasma was developed using liquid chromatography/tandem mass spectrometry (LC–MS/MS). The most abundant ions corresponding to SHS15 free polyethyleneglycol (PEG) oligomers at m/z 481, 525, 569, 613, 657, 701, 745, 789, 833, 877, 921 and 965 were selected for pMRM in electrospray mode of ionization. Purity of the lipophilic and hydrophilic components of SHS15 was estimated using evaporative light scattering detector (ELSD). Plasma concentrations of SHS15 were measured after oral administration at 2.50 g/kg dose and intravenous administration at 1.00 g/kg dose in male Sprague Dawley rats. SHS15 has poor oral bioavailability of 13.74% in rats. Differences in pharmacokinetics of oligomers were studied. A novel proposal was conveyed to the scientific community, where formulation excipient could be analyzed as a qualifier in the analysis of new chemical entities (NCEs) to address the spiky plasma concentration profiles.

Aptamer-based label-free detection of PDGF using ruthenium(II) complex as luminescent probe

We report a simple, cost-effective, and label-free detection method, consisting of a platelet-derived growth factor (PDGF) binding aptamer and hydrophobic Ru(II) complex as a sensor system for PDGF. The binding of PDGF with the aptamer results in the weakening of the aptamer-Ru(II) complex, monitored by luminescence signal. A substantial enhancement in the luminescence intensity of Ru(II) complex is observed in the presence of aptamer due to the hydrophobic interaction. Upon addition of PDGF, the luminescence intensity is decreased, due to the stronger interaction between the aptamer and PDGF resulting in the displacement of Ru(II) complex to the aqueous solution. Our assay can detect a target specifically in a complex medium such as the mixture of proteins, at a concentration of 0.8 pM.

Discovery of adamantane based highly potent HDAC inhibitors

Herein, we report the development of highly potent HDAC inhibitors for the treatment of cancer. A series of adamantane and nor-adamantane based HDAC inhibitors were designed, synthesized and screened for the inhibitory activity of HDAC. A number of compounds exhibited GI50 of 10-100 nM in human HCT116, NCI-H460 and U251 cancer cells, in vitro. Compound 32 displays efficacy in human tumour animal xenograft model.

Development and validation of a liquid chromatography-tandem mass spectrometry method for quantitation of indomethacin in rat plasma and its application to a pharmacokinetic study in rats

A highly sensitive and rapid bioanalytical method has been developed and validated for the estimation of indomethacin in rat plasma with liquid chromatography coupled to tandem mass spectrometry with electrospray ionization in the positive-ion mode. The assay procedure involves a simple liquid-liquid extraction of indomethacin and phenacetin (internal standard, IS) from rat plasma with acetonitrile. Chromatographic separation was achieved with 0.2% formic acid-acetonitrile (25:75, v/v) at a flow rate of 0.60 mL/min on an Atlantis dC18 column with a total run time 3.0 min. The MS/MS ion transitions monitored were 357.7 → 139.1 for indomethacin and 180.20 → 110.10 for IS. Method validation and pharmacokinetic study plasma analysis were performed as per FDA guidelines and the results met the acceptance criteria. The lower limit of quantitation achieved was 0.51 ng/mL and the linearity was observed from 0.51 to 25.5 ng/mL. The intra- and inter-day precisions were in the range of 1.00-10.2 and 5.88-9.80%, respectively. This novel method has been applied to an oral pharmacokinetic study in rats.